Healthcare Provider Details

I. General information

NPI: 1972216950
Provider Name (Legal Business Name): LAKISHA ANTOINETTE SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2023
Last Update Date: 12/13/2025
Certification Date: 12/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4624 PLAYER DR NE
ROANOKE VA
24019-5828
US

IV. Provider business mailing address

4624 PLAYER DR NE
ROANOKE VA
24019-5828
US

V. Phone/Fax

Practice location:
  • Phone: 540-915-4576
  • Fax:
Mailing address:
  • Phone: 540-915-4576
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number0002094509
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: